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Care Quality Commission publishes report on use of nasogastric tubes at North Cumbria University Hospitals NHS Trust
The Care Quality Commission has published findings from a focussed inspection at North Cumbria University Hospitals NHS Trust in July to look at the safety of nasogastric tube usage following findings published by Her Majesty’s Coroner.
The senior coroner for Cumbria concluded an inquest on 16 January 2017 into the deaths of two patients (Patient A and Patient B) cared for by the trust. This followed a separate, earlier inquest into the death of a patient at the trust in 2008 due to a misplaced nasogastric tube.
The inspection across medical, surgical, paediatric and intensive care wards at Cumberland Infirmary and West Cumberland Hospital, was also to check on the trust’s progress in delivering the action plan in response to the coroner’s concerns.
Inspectors found the insertion and management of nasogastric tubes was now safe, effective and well led. Findings included:
- Staff assessed the needs of patients and delivered care in line with existing policies. Procedures were also compliant with national best practice guidance.
- There had been no serious incidents regarding nasogastric tubes since April 2015.
- Clinical staff involved in the insertion of a nasogastric tube were now required to complete face to face training.
- Clear processes were in place to manage the progress of the action plan developed in response to the coroner’s concerns
Areas where CQC has told the trust it should improve:
- The trust should ensure the proposed new nasogastric insertion record for patient care plans is more detailed and contains more guidance as well as a summary of the reasons why the patient has one.
- The trust should develop a specific policy around the use of nasogastric tubes for pregnant women.
There are no ratings produced as a result of this inspection and the trust remains rated as Requires Improvement overall.
The full report of the inspection can be found on our website.
For further information please contact CQC Regional Engagement Officer Kerri James by email firstname.lastname@example.org or by phone on 07464 92 9966.
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- Last updated:
- 11 October 2017
Notes to editors
Patient A died in December 2012 at West Cumberland Hospital, Whitehaven, following the insertion of a nasogastric tube into his left lung resulting in the patient developing aspiration pneumonia. The pneumonia developed because the nasogastric tube was placed in such a way as to enter the left lung instead of the stomach.
Patient B died in April 2015 at the Cumberland Infirmary, Carlisle, following the insertion of a nasogastric tube into the right lung resulting in the patient developing aspiration pneumonia.
The pneumonia developed because the nasogastric tube was placed in such a way as to enter the right lung instead of the stomach.
Although the individual circumstances were different, HM Coroner issued two ‘Regulation 28 Report to Prevent Future Deaths’ notices to the trust. These contained common themes regarding the management of nasogastric tubes which are included in the report.
- Are they safe?
- Are they effective?
- Are they caring?
- Are they responsive to people’s needs?
- Are they well-led?